1

CE
A 100-Year Journey from
GV Black to Minimal
Surgical Intervention

Abstract
Mark S Wolff, DDS, PhD Over the past 140 years, dentistry has matured from the original tenets of GV Black
Professor and Chair by moving from “extension for prevention” to a minimal intervention approach. This
is part of an evolution that stresses a medical, rather than a surgical model for caries
Kenneth Allen, DDS, MBA management. This transition has been facilitated by the introduction and advance-
Assistant Professor
ment of adhesive dentistry, which encourages preservation of tooth structure. Even
James Kaim, DDS with these changes, some of the original writings of Black are still relevant today:
Professor and Associate Chair “The day is surely coming…when we will be engaged in practicing preventive, rather
Department of Cariology and
than reparative, dentistry.”
Comprehensive Care
New York University College of Dentistry
New York, New York
Learning Objectives
After reading this article, the reader should be able to:
• explain the history behind “extension • explain how the introduction of etch-
for prevention” and why it no longer ing and bonding has played a key role
applies. in minimally invasive dentistry.
• discuss why an indirect composite • describe the advances achieved based
restoration may be a better choice on the changes made to the composi-
than a crown when a single cusp is tion of amalgam.
fractured.

M
inimally invasive dentistry
(MID), or minimal interven-
tion dentistry, is a dental care
concept based on the assessment of a
patient’s caries risk and the application
of the current therapies to prevent, con-
trol, and treat the disease.1,2 It is often
referred to as treating dental caries with
a biologic, therapeutic, or medical
model.3 Tyas and colleagues state that
the MID model has several tenets
including, at a minimum, the follow-
ing3: (1) remineralization of early lesions;
(2) reduction in cariogenic bacteria to
eliminate the risk of further demineral-
ization and cavitation; (3) minimal sur-
gical intervention of caries lesions; (4)
repair rather than replacement of defec-
tive restorations; and (5) disease con-
trol. Although MID includes risk
assessment, remineralization, and bac-
terial management, this article will dis-
cuss the operative aspects of MID. The
minimal surgical procedures currently
performed are different from the opera-
tive dentistry practiced a generation
ago. This article will discuss how the
new operative dentistry has been
derived from the tenets of GV Black
published over a century ago.
Black published a series of papers
and texts on dental materials and
preparation and restoration techniques
between 1869 and 1915. Although
many current authors have credited or
blamed these tenets for overly aggres-
sive preparations and restorations in
modern dentistry,2,4 the present authors
contend that Black was the first dentist
to propose treating dental caries using
minimal intervention based on the
knowledge and materials available at
that time.
In the middle of the 19th century,
the exact cause of dental caries was
unknown. Dental preparations were

130 Compendium • March 2007;28(3):130-135

designed at the option of the operating dentist. Dental
amalgam, frequently formulated by the dentist, had little
standardization, which resulted in materials demonstrat-
ing poor performance. Black, a dentist of considerable
experience and observational skills, noted the frequent
failure of dental amalgam restorations with recurrent
caries at the corroded margins of the restorations. The
restorations of that time used an alloy that corroded rap-
idly and experienced problems with expansion; there-
fore, they failed relatively quickly. Patients were observed
to develop caries on virgin interproximal surfaces
because of the stagnation of food in these uncleansable
areas. Patients also were observed to develop caries
around occlusal restorations that failed to include sus-
ceptible pits and fissures.
Black wrote a series of papers that addressed the
problems of caries at the margins of restorations,5-7 amal-
gam composition,8 and tooth restorations.9 These papers
represented the earliest workbooks on the quality of
operative dentistry of that era, and these papers were
based on the best knowledge available. Black described
the placement of the outer enamel margins in “self-
cleansable areas” so that they terminated in regions less
susceptible to recurrent caries. Black wrote:
“Certainly that portion near the proximate contact…is
most liable to be attacked; and the liability diminishes as we
recede from that point.… It is to cut the enamel margins
from lines that are not self-cleansing to lines that are self-
cleansing.…When a cavity has occurred in the occluding
surface of a molar, the dentist prepares for filling with the
idea that the fissures in this part of the enamel have favored
the occurrence of the cavity. For this reason, the fissures and
grooves adjoining the cavity, even though not decayed, are
cut away to such a point as seems to give opportunity for a
smooth, even finish of the margins of the filling. This is done
as a prevention of future recurrence of decay.…”
The restorations of that time used
an alloy that corroded rapidly and
experienced problems with expansion.
This led to the now infamous term “extension for
prevention,” which could be summarized as “…the
removal of the enamel margin by cutting from a point of
greater liability to a point of lesser liability to recurrence
of caries.…” Black developed an amalgam alloy less like-
ly to corrode and suffer marginal breakdown, whose for-
mula remained essentially unchanged until the 1970s
when high copper silver amalgams were introduced.10
Black developed standard and meticulous placement
techniques for dental amalgam that used proper isolation:
“…Restorations of cohesive gold and amalgam… require
the application of the rubber dam….The student or den-
tist who earnestly desires to give the best service will,
when in doubt, apply the rubber dam.” This remained the
Compendium • March 2007;28(3):130-135
state of dental education and clinical practice until the
1950s, 1960s, and 1970s. During this period, several
events occurred that allowed for the improvement of den-
tal amalgams and the introduction of bonded restorations:
(1) Amalgams were improved by the development of a
process where the amalgam alloy was triturated with the
ideal quantity of mercury (Eames Technique11); (2) clini-
cal research resulted in the determination that higher cop-
per content alloys have less creep and marginal break-
down12-14; and (3) clinical research demonstrated that
smaller preparations last longer.15 These breakthroughs
each led to changes in preparation design and restorations
that were smaller and more effective.
During this period, several events
occurred that allowed for the improvement
of dental amalgams and the introduction
of bonded restorations.
It is in the breakthroughs associated with bonding
that MID has had its greatest advances. In 1955,
Buonocore described a technique for etching enamel sur-
faces to make them retentive for a restoration.16 In 1962,
Bowen submitted a patent, entitled a “Dental filling
material comprising vinyl silane treated fused silica and
a binder consisting of BIS phenol and glycidyl acrylic,”
that enabled the restoration of a tooth with a tooth-col-
ored plastic better known today as Bis-GMA. These 2
developments have led to the creation of tooth conserva-
tion or minimally invasive surgical dentistry.
Discussion
Dentists have a variety of treatment options for the
restoration of cavitated caries lesions. Restoration
options range from minimal tooth preparation on the
occlusal surface to placement of a crown over the entire
coronal tooth structure. What factors determine the
treatment decisions? The minimal intervention philoso-
phy mandates that the least invasive effective therapy,
preparation, and restoration be used to restore lesions
with cavitation. This philosophy maintains as a tenet that
surface demineralization is the first stage in the develop-
ment of a caries lesion and is a condition that may be
reversed with remineralization therapy (not discussed in
this paper17-19). The basic philosophy recognizes the fact
that all restorations have a finite life and that large
restorations (composite or amalgam) have a shorter
longevity than smaller ones.15
Black made a similar observation over a century ago
(1891) saying: “…And if the filling should serve for five,
ten, or fifteen years, valuable teeth will have been saved
to the patient that much longer by filling and afterward
crowning, than by present crowning....” In other words,
always choose the least invasive option because the more
invasive option is usually available for a later date. The
131
 ble groove or grooves
receive an acid-etched pit
and fissure sealant materi-
al (Figure 1C). The his-
toric rationale for removal
of the groove was preven-
tion of future caries. The
concern of future caries in
the groove is easily dealt
with by placement of a
sealant, a technique well
Figure 1—(A) Minor decay isolated to the pit areas on a maxillary molar. (B) Typical amalgam restoration removing the documented over the past
entire groove. (C) Preventive resin restoration, removing decay from the pits and sealing the remaining groove structure
(adapted from Ripa, LW and Wolff MS, 1992). 25 years to prevent caries.22
It has even been demon-
strated that properly placed sealants, even if placed over
active caries, have the ability to arrest caries activity for
more than a decade.23 This is the same concept as Black’s
extension for prevention but uses the advantages of the
relatively new restorative materials without the need for
surgical extension.
Minimally invasive surgical procedures apply to
restoration of the proximal surface as well. A proper diagno-
sis of the location of the caries is essential. Caries that can
be identified radiographically on the proximal surface as
penetrating at least to the dentoenamel junction (some
would advocate penetration even further before interven-
Figure 2—Caries present to the dentoenamel junction (DEJ) on the distal of the tion) requires preparation and removal. The conventional
maxillary first and second bicuspid, almost to the DEJ on the mesial of the “Black” preparation requires the incorporation of the
maxillary second premolar, and minimal penetration on the mesial of the max-
illary first molar. Note the occlusal caries on the mandibular first molar. occlusal groove as part of the restoration. Minimal interven-
tion mandates that the groove remain intact unless there is
following are a few examples of the application of MID caries on the surface (even if it is stained) (Figure 2). If the
principles with esthetic restorations: groove is intact, it can be sealed at the end of the procedure.
The changes in the paradigms for restoration of The preparation of the proximal box for the “slot”
occlusal caries lesions using a bonded restoration are preparation differs from the design discussed by Black,
among the most dramatic changes in treatment philoso- which requires that the margins be brought into a cleans-
phy. Black recommended the removal of the entire groove able area of the interproximal embrasure. Where possible,
and the placement of an amalgam regardless of the size of for composite restorations, the facial and lingual embra-
the caries lesion (Figure 1A). This protected the unin- sures are designed to remain closed, providing that the
volved groove from future caries (Figure 1B). Minimal decay can be accessed and removed. As proximal caries
intervention on the occlusal surface was first described by generally occur gingival to the contact area, the gingival
Simonsen20 and refined by Ripa and Wolff21 as a preventive embrasure must always be open to ensure the removal of
resin restoration. The preventive resin preparation all decay (Figure 3A). After the decay is excavated and the
requires the removal of only the caries lesion followed by final restoration is placed, the remaining grooves receive
a composite restorative material. The remaining suscepti- a sealant to complete the restoration (Figure 3B).

Figure 3A—Decay is exposed and excavated. Facial and lingual walls may Figure 3B—Tooth is restored with composite and the occlusal surface is
not require removal depending on the extension of the caries. sealed.

132 Compendium • March 2007;28(3):130-135

Figure 4A—Lateral incisor with a diastema.
Posterior teeth requiring cusp replacement can be
restored using gold restorations as described by Black over
100 years ago. These gold restorations may be an onlay
replacing only missing tooth structure. The teeth also may
be restored using full-coverage crowns. The process of
preparing a full crown involves the destruction of a signif-
icant amount of sound tooth structure to develop parallel
walls to create a retentive preparation. A minimally inva-
sive esthetic alternative restoration could be the placement
of a direct placement composite. However, large direct
composite restorations are difficult to place because of the
need to both maintain strict and complete isolation for
long periods of time and to achieve good physiological
contours with well-polished interproximal areas.
These teeth, requiring replacement of a cusp, also may
be restored using indirect composite or porcelain materials.
The indirect onlay restorations take advantage of the abili-
ty to design and produce a restoration outside the mouth.
The restorations may be adjusted, modified, and recon-
toured, providing ideal contours in the dentist’s or techni-
cian’s hands. These large, indirect esthetic restorations may
be prepared with minimal destruction of additional sound
tooth structure as would occur in the fabrication of full-
coverage crowns. The onlays are bonded into the prepara-
tion so that there is less need to design the restorations to
be mechanically retentive (beyond the bonding).
The changes in the paradigms for restoration
of occlusal caries lesions using a bonded
restoration are among the most dramatic
changes in treatment philosophy.
These restorations can be fabricated using either indi-
rect laboratory techniques or using computer-aided design
and computer-assisted manufacturing (CAD/CAM). The
laboratory indirect technique involves making an impres-
sion of the preparation, temporization, and the return for a
second visit for the final insertion. The CAD/CAM tech-
nique involves an optical impression, computer design of
the restoration, and a final milling of the onlay during the
patient visit. These restorations, when etched and treated
with silane, are bonded in place using composite resins
modified from the original Bowen composition.
Compendium • March 2007;28(3):130-135
Figure 4B—Lateral incisor with diastema closed with composite.
The philosophy of minimal surgical intervention and
minimal tooth destruction extends to the anterior esthet-
ic procedures (eg, diastema closure and peg laterals). The
addition of a small amount of direct bonded composite, a
well-respected art form in the 1980s, can still be used
rather than aggressively preparing the tooth for a porce-
lain laminate or full-coverage porcelain crown. The final
restorative results are esthetic, functional, and can be
repaired or replaced without any tooth destruction.
(Figures 4A and 4B).
The final restorative results are esthetic,
functional, and can be repaired or replaced
without any tooth destruction.
Minimal surgical intervention possibilities have been
further expanded by the introduction of new technolo-
gies. Hard-tissue lasers, air abrasion, and mini-burs make
smaller, less invasive preparations possible. Each device
permits the clinician to use a more conservative, less
destructive approach toward the removal of infected
tooth structure. These devices, along with adhesive den-
tistry, allow for a truly defect-specific approach toward
caries removal.
Conclusion
MID is the natural evolution of dentistry. As new
materials and techniques are developed, dentistry is obli-
gated to review and use the most conservative techniques.
Overly aggressive tooth preparation results in increased
incidence of unneeded sequelae, often at great pain and
expense for the patient. The concept of MID is more than
a series of “surgical” techniques. MID is a comprehensive
package of dental care and caries intervention that
involves: (a) identifying patients for risk of developing
dental caries using existing oral and health conditions as a
predictor24; (b) implementing aggressive preventive strate-
gies including fluoride therapy, antimicrobial therapy, diet
modification, xylitol and calcium supplementation to
reduce the risk such as those described in the tenet of min-
imal intervention3; and (c) conservative use of surgical
dentistry to improve the well-being of the patient at the
133

lowest monetary cost, preserving the maximum amount of
tooth structure.
MID recognizes that dental caries is a reversible dis-
ease that starts with demineralization of the tooth and
may eventually progress to cavitation if the risk factors
are not brought under control. Black commented back in
1896 on the future of dentistry and the philosophy of
prevention in a speech to young dentists25:
“The day is surely coming and perhaps within the
lifetime of you young men before me, when we will be
engaged in practicing preventive, rather than reparative
dentistry. When we will so understand the etiology and
pathology of dental caries that we will be able to combat
its destructive effects with a systemic medication.”
References
1. McIntyre J. Minimal intervention dentistry. Ann R Aust Coll
Dent Surg. 1994;12:72-79.
2. Chalmers JM. Minimal intervention dentistry: part 1.
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patients. J Can Dent Assoc. 2006;72:427-433.
3. Tyas MJ, Anusavice KJ, Frencken JE, et al. Minimal interven-
tion dentistry—a review. FDI Commission Project 1-97. Int
Dent J. 2000;50:1-12.
4. Mount GJ. Minimal intervention dentistry: rationale of cavity
design. Oper Dent. 2003;28:92-99.
5. Black GV. The management of enamel margins. Dental Cosmos.
1891;33:1-14.
6. Black GV. The management of enamel margins. Dental Cosmos.
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8. Black GV. The effect of oxidation on cut alloys for dental amal-
gams. Dental Cosmos. 1896;38:43-48.
9 Black GV. A Work on Operative Dentistry in Two Volumes.
Chicago, Ill: Medico-Dental Publishing Co; 1908.
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Res. 1997;76:537-541.
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position, and alloy to fracture at the margins of 13- to 14-year-
old amalgams. J Dent Res. 1990;69:1599-1601.
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Books and Software; 2005:111-118.
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19. Tung MS, Eichmiller FC. Amorphous calcium phosphates for
tooth mineralization. Compend Contin Educ Dent. 2004;25(9
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technique, and success. Quintessence Int. 1992;23:307-315.
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Quiz1
1. Tyas and colleagues state that minimally inva-
sive dentistry (MID) model has several tenets
including:
a. demineralization of early lesions.
b. reduction in cariogenic bacteria.
c. replacement rather than repair of defective
restorations.
d. all of the above
6. The basic philosophy of minimal intervention
recognizes the fact that all restorations have a
finite life and that large restorations have
______ smaller ones.
a. greater longevity than
b. a shorter longevity than
c. the same longevity as
d. equal to greater longevity than

2. In the middle of the 19th century, the exact 7. As described by Simonsen, the preventive
cause of dental caries was: resin restoration requires the removal of only
a. bacteria. the caries lesion followed by:
b. fungus. a. an amalgam restoration and sealant.
c. mold. b. a silicate cement restoration and sealer.
d. unknown c. a composite restorative material.
d. an acrylic (mma) resin and sealer.
3. Black wrote a series of papers that addressed
the problems of: 8. The conventional “Black” preparation requires
a. tooth restorations. the incorporation of the _____ as part of the
b. amalgam composition. restoration.
c. caries at the margins of restorations. a. occlusal groove
d. all of the above b. gingival margin
c. dentoenamel junction
4. Black developed an amalgam alloy less likely d. lingual surface
to corrode and suffer marginal breakdown,
whose formula remained essentially 9. Which device permits the clinician to use a
unchanged until when? more conservative, less destructive approach
a. 1950s toward the removal of infected tooth structure?
b. 1960s a. air abrasion
c. 1970s b. mini-bur
d. 1980s c. hard-tissue laser
d. all of the above
5. The process where the amalgam alloy was trit-
urated with the ideal quantity of mercury is 10. MID recognizes that dental caries is a
called the: reversible disease that starts with what?
a. Eames Technique. a. caries lesion
b. Black Technique. b. demineralization of the tooth
c. Osborne Technique. c. cracked restoration
d. Mercury Technique. d. spontaneous bleeding

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